Rio Bravo qWeek

Episode 131: Breastfeeding Part 2

Lia and Aruna explain some updates given by the American Academy of Pediatrics regarding breastfeeding. Dr. Arreaza adds some comments about breastfeeding. 

Written by Aruna Sridharan, MS4, and Lia Khachikyan, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

The motivation for this episode was a recent publication by the American Academy of Pediatrics, on June 27, 2022, titled Policy Statement: Breastfeeding and the Use of Human Milk. During this episode, we included updated information along with other useful material.

Duration of breastfeeding:

The American Academy of Pediatrics (AAP), World Health Organization (WHO), and Center of Disease Control (CDC) recommend exclusive breastfeeding at least for the first 6 months, after which one can start to introduce complementary pureed foods. The US Department of Agriculture states that initiating complementary foods earlier than 6 months offers no benefit to the baby and can even be associated with a higher risk of overweight or obesity, especially if introduced before 4 months. Mothers are then encouraged to continue breastfeeding for at least one year and can further continue up to 2 years of age or longer - as long as mutually desired by mother and child. This is an update from previous recommendations regarding the duration of breastfeeding until 1 year of age.

Composition of human breastmilk:

As the sole source of nutrition for infants in the first 6 months of life, breast milk plays a critical role in development. Human milk has a unique composition of proteins, fats, and lactose, as well as vitamins, electrolytes, antimicrobial, anti-inflammatory immunoregulatory agents, and living leukocytes, all of which contribute to the developing immune system of the child. Breast milk is rich in Vitamins B1, B2, and B6, Vitamins C, A, E, Ca, Mg, phosphate, and folate. 

However, it is low in Vitamins K, D, B12, and iron, therefore supplementation of these nutrients is required. It is important for mothers to consume an adequate and healthy diet for their breastmilk to contain appropriate levels of these nutrients. 

Water-soluble and Fat-soluble vitamins can be low in breast milk if the mother has a deficiency. Selenium can be low if maternal serum levels are low. Dietary iodine deficiency may also be exacerbated by smoking; iron deficiency; and consumption of large amounts of foods that interfere with the production of thyroid hormones, known as goitrogens, including Brussels sprouts, kale, cabbage, cauliflower, and broccoli. 

Maternal diet:

Mothers should consume iodine-rich foods, such as lean meat, eggs, dairy, beans, and lentils. It is important to choose a variety of whole grains, as well as fruits and vegetables, and continue taking multivitamins. Fun fact: Different foods will change the flavor of your breast milk. This will expose your baby to different tastes, which might help him or her more easily accept solid foods down the road! It is recommended that mothers consume 290 mcg of iodine and 550mg of choline a day. 

Is there anything that mothers should avoid in their diet?

-Limit seafood: Although fish is a good source of protein and lean meat, it contains some mercury, which can be transferred to the baby’s diet. High amounts of mercury can have an adverse effect on the baby’s brain and nervous system.

-Limit caffeine: Also, we know a lot of people love their morning dose of espresso! Low to moderate amounts, equivalent to 2-3 cups of coffee per day, do not adversely affect the infant. However, anything more than around 300 mg of caffeine can cause irritability, poor sleeping patterns, fussiness, and jitteriness. Remember! This also includes sodas, energy drinks, tea, and even chocolate! As a reminder, one cup of coffee can have 95mg of caffeine.

Vegan mothers: Vegetarian/vegan mothers may have very limited amounts of vitamin B12 in their bodies, which can result in neurological damage to the baby. Iron levels may also be sparse since plant-based foods only contain non-heme iron, which is less absorbable than heme iron. The American Dietetic Association recommends supplementation of vitamin B12, iron, and other nutrients such as choline, zinc, iodine, or omega-3 fats. 

Benefits:

For the baby: Studies show that exclusively breastfeeding for 6 months decreased rates of neonatal and infant mortality as well as pediatric disorders such as otitis media, diabetes mellitus, obesity, lower respiratory tract disorders, asthma, atopic dermatitis, sudden infant death syndrome (SIDS), severe diarrhea, and inflammatory bowel disease. The longer an infant is breastfed, the greater the protection from certain illnesses and long-term diseases. 

For the mother: The longer a mother breastfeeds, the greater the benefits to her health as well. Mothers who breastfeed experience a lower risk of hypertension, type 2 diabetes, and breast, ovarian, and endometrial cancers. 

Contraindications:

-Alcohol: Having up to 1 drink per day is not harmful to the baby, especially if the mother waits at least 2 hours before feeding the infant. This allows time for the blood alcohol concentration in the breastmilk to decrease. Consuming more than 2 standard alcoholic drinks daily is highly discouraged.

-Tobacco: Cigarette smoking, or the use of nicotine products, is associated with decreased production of milk, shorter lactation time, and an increased risk of SIDS, asthma, and other respiratory illnesses in infants. Therefore, mothers should be strongly encouraged to stop smoking and minimize secondhand exposure. We know it is very difficult for people to quit abruptly. While transitioning to cessation, mothers should be counseled to smoke right after breastfeeding to allow the greatest amount of time for nicotine to exit the body until the next feed. Other cessation alternatives such as the patch or gum can also be used during breastfeeding.

Varenicline: No human data is available to assess the risk of infant harm, but it is likely excreted in the milk, no data on the assessment of milk production.

-Other substances: Marijuana, opioids, amphetamine, cocaine, and other illicit drugs are contraindicated due to their effects on neurodevelopmental behaviors. If these substances have been used intrapartum or during breastfeeding, it is important to monitor the baby for Neonatal Abstinence Syndrome. Some symptoms include poor weight gain, tremors, high-pitched crying, stuffy nose, poor feeding/sucking, seizures, irritability, poor sleep, vomiting, and diarrhea.

-Maternal infections: Breastfeeding is not contraindicated during most maternal infections. Some exceptions include HIV, Human T-cell lymphotropic virus type I or II, untreated brucellosis, Ebola virus, or active Herpetic lesions on the breast. Women with herpetic lesions may breastfeed from the unaffected breast. 

-Maternal medications: Medications are relatively safe for breastfed babies, but some contraindications include anticancer drugs, oral retinoids, lithium, iodine, and amiodarone. Mothers should go over their medication list with their primary physician.

Pregnancy and Lactation Labeling Final Rule (PLLR): Classification of drugs according to their impact on pregnancy and breastfeeding (categories A, B, C, D, X) was started in 1979, but it was stopped in 2015 and replaced by the Pregnancy and Lactation Labeling Final Rule (PLLR). The former categories were replaced with narrative sections and subsections to include: Pregnancy (including labor and delivery), Lactation, and information for Females and Males of Reproductive Potential (pregnancy testing, contraception, infertility).

Role of the physician and stigmas:

It is well known that breastfeeding can strengthen the bond between the mother and her child. Therefore, when latching becomes a problem, mothers are quick to become discouraged. If this happens, pediatricians should educate the parents that many breastfeeding problems commonly arise between 4-7 days after birth. Sometimes, exclusive or any amount of breastfeeding is not always possible, despite the mother’s best intentions. This can understandably cause them to feel a lot of guilt and disappointment as a new mother. 

Physicians should provide a safe, non-judgmental environment for the parents to openly discuss their difficulties while educating them on proper latching techniques and other alternatives for breastfeeding.

Conclusion: Now we conclude our episode number 131 “Breastfeeding Part 2.” Aruna and Lia explained that the American Academy of Pediatrics now recommends continued breastfeeding until 2 years or as long as the mother and the baby desire it. It is important to remember some contraindications such as babies with galactosemia, mothers who are using illicit drugs, and some maternal infections such as HIV, untreated brucellosis, and Ebola virus. 

This week we thank Hector Arreaza, Aruna Sridharan, and Lia Khachikyan. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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1. Dror, D. K., & Allen, L. H. (2018, May 29). Overview of Nutrients in Human Milk. PubMed Central (PMC). https://doi.org/10.1093/advances/nmy022.
2. Meek, J. Y., Noble, L., & Breastfeeding, S. O. (2022, July 1). Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics. https://doi.org/10.1542/peds.2022-057988.
3. “Maternal Diet.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 May 2022, https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html.
4. Breastfeeding FAQs. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/faq/index.htm. Accessed February 21, 2023. 
5. Butte, Nancy F., and Alison Stuebe. Maternal nutrition during lactation. UpToDate, July 13, 2022. https://www.uptodate.com/contents/maternal-nutrition-during-lactation. Accessed March 6, 2023. 
6. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Saakshi and Dr. Arreaza discuss some principles of epigenetics implicated in the development of obesity in children. 

Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

This topic is constantly expanding, and I’m excited to talk about it. It is a fact that epigenetic changes play a role in the development of certain diseases such as Prader-Willi syndrome, Fragile X syndrome, and various cancers. It has been demonstrated that certain foods can alter gene expression in animals, for example. 

What is epigenetics?

Epigenetics is the regulation of gene expression without a change in the base sequence of DNA. Epigenetics means “on top of” the genes. Genes can be turned “on” or “off” as a response to external influences. 

Obesity and Epigenetics.

The link between genetics and obesity is complex, but it is known that epigenetics plays a significant role in childhood obesity. Surprisingly, exposure to environmental factors starts in the uterus. 

Fetuses are exposed to intrauterine signals that increase their potential to develop obesity. Factors such as in-utero hyperglycemia, gestational diabetes mellitus, and early childhood diet and lifestyle practices can affect the development of the gut microbiome, modify gene expression through DNA methylation, and increase the risk of childhood obesity. 

These gene expression changes can be passed on to future generations. DNA methylation is the addition of a methyl group to part of the DNA molecule. That methyl group acts as a “chemical cap,” which prevents gene expression. Another example of epigenetics is histone modification. Histones are proteins that are used by DNA as spools to wrap around pieces of information that are “not needed”. The reason why a scalp cell and a neuron are different is that the expression of certain genes is suppressed while other genes are expressed.

Factors that influence obesity.

Some factors that increase the risk of childhood obesity through epigenetic changes include neonatal intestinal microbiome, C-section delivery, maternal insulin resistance, exposure to antibiotics and other environmental toxins, early introduction of complementary foods, parental diets high in carbohydrates and low in fruits and vegetables, and poor sleep. There are many other factors, but we will discuss only a few of them.

Microbiome:

The microbiome is a whole new world that is being explored by many investigators. The gut microbiome refers to the diverse community of organisms, including bacteria, fungi, and viruses, that reside in the human intestine. The neonatal intestinal microbiome is established during the first two years of life and may be influenced by factors such as the method of delivery, maternal obesity, and the maternal gut microbiome. 

Some bacteria worth mentioning are Bacteroides, Clostridium, and Staphylococcus. These gut bacteria are higher in pregnant women who have obesity, and they also have a low count of Bifidobacterium. Infants born to obese mothers have higher levels of bacteria associated with increased energy harvest compared to infants born to normal-weight mothers. The gut microbiome of infants delivered by C-section is different than infants delivered vaginally.

Link to antibiotics:

Early exposure to antibiotics is associated with the development of resistance in microorganisms. The intestinal microbiota exposed to antibiotics also shows reduced diversity. Antibiotics can decrease the number of mitochondria and impair their function, which is important in maintaining energy metabolism. Evidence suggests that some antibiotics can cause mutations in the mitochondrial genome, and they have a direct effect on the microbiome and influence metabolism. There is a strong association between early-life antibiotic exposure and childhood adiposity, with a strong dose-response relationship. A stronger association has been seen with exposure to broad-spectrum antibiotics and macrolides. 

Maternal insulin resistance (IR):

Insulin resistance means that the mother needs levels of insulin that are higher than normal to stay normoglycemic. It means the insulin receptors are “exhausted” and do not respond to normal levels of insulin. Insulin does NOT cross the blood-placenta barrier, but glucose and other nutrients do. This causes the fetus to have an abundance of glucose that stimulates the secretion of high levels of insulin by the fetal pancreas to stay normoglycemic. The combination of insulin + glucose is the perfect combination for anabolism, adipocyte hyperplasia, and fetal growth. That explains why mothers with insulin resistance deliver larger babies (macrosomia). 

Maternal insulin resistance is a predictor of infant weight gain and body fat in the first year of life. This is not influenced by the mother's BMI before pregnancy. Maternal insulin resistance causes alterations in gene regulation for lipids, amino acids, and inflammation, leading to long-term health implications for both the mother and future pregnancies.

C-section and obesity:

C-section delivery is a saving procedure for many obstetrical emergencies. C-sections have improved the survival of larger infants and their mothers. C-sections are more frequent among populations with obesity and sedentary lifestyles. This method of delivery is also strongly associated with childhood obesity. Among many other reasons, whenever a vaginal delivery is feasible, a vaginal delivery is preferred over a c-section.   

In summary, we discussed 4 factors that may influence childhood obesity: the newborn microbiome, exposure to antibiotics, maternal insulin resistance, and C-sections. There are many other factors that we did not talk about, but the more we know about genetics, epigenetics, and metabolism, the closer we get to a better understanding of obesity.

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Conclusion: Now we conclude our episode number 130, “Epigenetics in childhood obesity.” Saakshi discussed with Dr. Arreaza that the in-utero environment can alter gene expression and increase the risk of obesity in children. Some factors, such as maternal insulin resistance and changes in gut microbiome, can be the cause of obesity in some children. This week we thank Hector Arreaza and Saakshi Dulani. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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Sources:

1. Burdge GC, Hoile SP, Uller T, Thomas NA, Gluckman PD, Hanson MA, Lillycrop KA. Progressive, transgenerational changes in offspring phenotype and epigenotype following nutritional transition. PLoS One. 2011;6(11):e28282. doi: 10.1371/journal.pone.0028282. Epub 2011 Nov 30. PMID: 22140567; PMCID: PMC3227644. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227644/
2. Rachael Rettner, Epigenetics: Definition & Examples, Live Science, published on June 24, 2013, available at: https://www.livescience.com/37703-epigenetics.html
3. Mulligan CM, Friedman JE. Maternal modifiers of the infant gut microbiota: metabolic consequences. J Endocrinol. 2017;235: R1-R12.
4. Aghaali, M. and S. S. Hashemi-Nazari (2019). “Association between early antibiotic exposure and risk of childhood weight gain and obesity: a systematic review and meta-analysis.” J Pediatr Endocrinol Metab 32(5): 439-445.
5. Yuan C, Gaskins AJ, Blaine AI, et al. Association between cesarean birth and risk of obesity in offspring in childhood, adolescence, and early adulthood. JAMA Pediatr. 2016;170(11):e162385. doi: 10.1001/jamapediatrics.2016.2385.
6. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 129: Emergency Contraception

Bailey describes the available methods of emergency contraception in the United States. 

Written by Bailey Corona, MS4, American University of the Caribbean. Editing by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Definition. 

Emergency contraception refers to therapy used after intercourse to prevent pregnancy. The need for emergency contraception can happen for many reasons, such as a condom breaking or failure to use contraception. More than 11% of sexually active women in the United States between ages 15 and 44 reports using emergency contraception at least once. With such high demand, a multitude of options has become available to meet these needs. With so many options on the market, it may be difficult to decide which option best fits the needs of each individual, which makes it important for providers to have a clear understanding of the risks and benefits associated with each method. 

Emergency contraception may be commonly used by young patients as their main contraception method. Let’s talk about the types of emergency contraception.

Levonorgestrel-only (Plan B®).

Levonorge’strel-only emergency contraception is the most popular option on the market today. More commonly known as “Plan-B”, this therapy works because of levonorgestrel’s similar make-up to progesterone. 

Mechanism of action.

High levels of progesterone delay follicular development so long as it is administered before the level of luteinizing hormone begin to rise. This gives contraceptive therapy of this class a therapeutic window of 72 hours which is the most limited window of all the methods discussed. Despite this shortcoming, Levonorgestrel contraception remains the most popular option because it can be purchased over the counter without the need of a physician and is available to women of all ages. Additionally, therapy includes only a single 1.5mg dose making noncompliance virtually non-existent. 

Side effects. 

Side effects include nausea in 12% of patients and headache in 19% of patients. According to one study, 16% of women reported self-resolving uterine bleeding within the first week after use.

Selective progesterone modulators (Ella®).

The second most commonly used form of emergency contraception are the selective progesterone receptor modulators or more widely known as Ella®. 

Mechanism of action.

Treatment includes a single 30mg dose of ulipristal acetate, which inhibits follicular rupture even after the luteinizing hormone has begun to rise. Due to this mechanism of action, selective progesterone receptor modulators have a wider therapeutic window of 5 days.

Side effects.

Side effects resemble that of progesterone-only therapy, significant for nausea and headache. Treatment has 2 major barriers preventing it from being the most widely used. Firstly, efficacy is decreased in women with a BMI greater than 35, and secondly, treatment requires a prescription from a medical professional. 

Estrogen-progesterone combination.

Estrogen-progesterone combination therapy is also a viable option for emergency contraception; however, it is no longer available as a dedicated product but can be made from a variety of oral contraceptives. Its decreased popularity is likely due to its increased incidence of nausea when compared to the other options available.

Copper IUD.

Lastly, Copper IUDs like Paragard can be used for emergency contraception despite not being FDA-approved for this purpose. Copper IUDs are highly effective if placed within 5 days of intercourse, but studies have shown therapy to be effective up to 10 days after. 

Mechanism of action.

Copper IUDs prevent fertilization by altering sperm viability and oocyte-endometrium interaction. This method is the most invasive as it requires placement by a physician and carries the rare risk of uterine perforation, occurring in around 1/1000 IUD placements. That said, copper IUD placement carries with it the added benefit of continued contraception for 10 years. It is contraindicated, however, in patients with a history of heavy menstrual bleeding. 

FAQs about emergency contraception:

1. Does increasing the availability of emergency contraception encourage risky sexual behavior?
   • No, according to a systematic review by Maria Rodrigues, there was no significant increase in sexually risky behavior correlated with increased availability of emergency contraception.
     • Rodriguez MI, et al.
2. What is the greatest barrier to emergency contraception use in the United States?
   • Education. A study by Abbott J, et al, interviewed adolescents receiving care in urban emergency rooms. The study showed that only 64% of patients had ever heard of emergency contraception. By educating patients of reproductive age on what options may be available to them it is expected that there would be a decrease in unplanned pregnancies. 
   • Additionally, studies like “knowledge of emergency contraception among women aged 18-44 in California” by Foster DG have gone further to establish that women of lower socioeconomic status, foreign birth, or who have not graduated high school also have suboptimal education in emergency contraception.
3. When should someone use emergency contraception?
   • Treatment should begin as soon as possible after unprotected intercourse in order to ensure maximum efficacy. 3 days for Plan B, 5 days for Ella, and 10 days for IUD.
4. How effective is emergency contraception?
   • The answer to this question differs based upon what method a patient decides to use
   • IUDs
     • A systematic review of 42 studies over a 35-year time period reports that pregnancy rates were between 0 and 2%.
       • The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience by Cleland K. et al. 
     • Oral regimens have been studied extensively and have shown that ulipristal acetate like Ella® are slightly more effective, showing a pregnancy rate of 1.4% and a rate of 2.2% in levonorgestrel-only pills like Plan B. 
       • Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis by Glacier AF.
5. Do patients require follow up after use of emergency contraception?
   • No. Only if there is a delay in the start of normal menses by greater than 1 week or if lower abdominal pain or persistent irregular bleeding develops.

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Conclusion: Now we conclude episode number 129 “Emergency Contraception.” Bailey explained that a pelvic exam is not needed in most cases before or after emergency contraception. Plan B® is available over the counter, while Ella® is available with a prescription. Copper IUD is not FDA-approved for emergency contraception, but evidence has shown it is an effective method. Dr. Arreaza suggested that, after learning more about emergency contraception, listeners can draw their own conclusions about the ethical dilemma of prescribing it to their patients. 

This week we thank Hector Arreaza and Bailey Corona. Audio editing by Adrianne Silva.

Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you; send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

____________________

Sources:

1. Abbott J, Feldhaus KM, Houry D, Lowenstein SR. Emergency contraception: what do our patients know? Ann Emerg Med. 2004 Mar;43(3):376-81. doi: 10.1016/S019606440301120X. PMID: 14985666. https://pubmed.ncbi.nlm.nih.gov/14985666/.
2. Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012 Jul;27(7):1994-2000. doi: 10.1093/humrep/des140. Epub 2012 May 8. PMID: 22570193; PMCID: PMC3619968. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/.
3. “Emergency Contraception.” ACOG, https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception.
4. Foster DG, Harper CC, Bley JJ, Mikanda JJ, Induni M, Saviano EC, Stewart FH. Knowledge of emergency contraception among women aged 18 to 44 in California. Am J Obstet Gynecol. 2004 Jul;191(1):150-6. doi: 10.1016/j.ajog.2004.01.004. PMID: 15295356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/
5. Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, Sogor L, Blithe DL, Scherrer B, Mathe H, Jaspart A, Ulmann A, Gainer E. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010 Feb 13;375(9714):555-62. doi: 10.1016/S0140-6736(10)60101-8. Epub 2010 Jan 29. Erratum in: Lancet. 2014 Oct 25;384(9953):1504. PMID: 20116841.https://pubmed.ncbi.nlm.nih.gov/20116841/
6. Jayson, Sharon. “5.8M Women Have Used 'Morning after' Pill.” USA Today, Gannett Satellite Information Network, 14 Feb. 2013, https://www.usatoday.com/story/news/nation/2013/02/13/cdc-contraception-emergency-methods/1914673/. 
7. Rodriguez MI, Curtis KM, Gaffield ML, Jackson E, Kapp N. Advance supply of emergency contraception: a systematic review. Contraception. 2013 May;87(5):590-601. doi: 10.1016/j.contraception.2012.09.011. Epub 2012 Oct 4. PMID: 23040139. https://pubmed.ncbi.nlm.nih.gov/23040139/.
8. von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002 Dec 7;360(9348):1803-10. doi: 10.1016/S0140-6736(02)11767-3. PMID: 12480356. https://pubmed.ncbi.nlm.nih.gov/12480356/.
9. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 128: Food insecurity and obesity.  

Nausheen defines food insecurity, presents some statistics about obesity, and how food insecurity is linked to obesity. She ends her presentation with possible solutions to this problem.

Written by Nausheen Hussain, OMS3, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.

Welcome: You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Arreaza: Hello, my name is Hector Arreaza. I am a family physician, currently practicing and teaching in the Central Valley of California. Today we will talk about an important and growing problem: Food insecurity and its relationship to obesity. I would like to introduce my guest today, Nasheen Hussain.

Arreaza: Can you tell me what defines food insecurity? 

Nausheen: As defined by the U. S. Department of Agriculture (USDA), food insecurity is the limited availability of nutritionally adequate food or the limited access to this food. So, I want you to imagine you are living in a community where the closest grocery store is not within walking distance, you have no reliable access to transportation, and you are surrounded by liquor stores, McDonald’s, and Burger King. Now you can see the two parts of that definition: the grocery store with healthy food exists, but it is too far, and you can't get to it. Whereas within walking distance is nonnutritious food. I want to challenge our audience to pay attention to these two concepts in the communities around them.

Arreaza: I have noticed a concentration of fast-food places lining certain streets. Now that we understand the concept, do we know if there is a way to quantify or measure food insecurity?  

Nausheen: Yes, Dr. Arreaza. So, the term “food swamp” actually describes what you just stated. To answer your question, yes. Food insecurity is actually measured by the USDA by a 6-18 item questionnaire - asking questions such as: Were you worried if food would run out before you got money to buy more? It is conducted as an annual supplement to the Current Population Survey. 

Arreaza: The Current Population Survey (CPS) is the primary source of labor force statistics for the population of the United States. It is sponsored jointly by the U.S. Census Bureau (bee-uro) and the U.S. Bureau of Labor Statistics (BLS). The CPS is conducted monthly. 

Nausheen: The 2021 questionnaire identified 12.5% of households in the U. S. as being food insecure. However, this may underestimate the true number of individuals who may be suffering from food insecurity. 

Arreaza: Screening for food insecurity is not been routinely done in many clinics. Food Insecurity: Preventive Services. An Update for This Topic is In Progress. LAST UPDATED: Jul 24, 2022. So now, let’s talk about the connection of this to obesity. What factors in general increase the likelihood of obesity?

Nausheen: Sure! Obesity is classified based on a person’s body mass index or BMI, which is your weight in kilograms (or pounds) divided by the square of height in meters (or feet). A BMI of 30 or greater is considered to be in the obesity category. Obesity is affected by several factors, such as a person’s genetics, level of activity, and a high-calorie diet consisting of low-nutrition food.

Arreaza: How does food insecurity play into this? 

Nausheen: Think back to the example we discussed earlier. If a person is experiencing food insecurity due to a lack of access, they will use what is around them (fast food, 24-hour mart without fresh foods) so they can put food on the table. If it is due to financial inaccessibility, they will choose to, say, go to Jack in the Box for their $5.00 deals. Both of these lead to a diet filled with non-nutritious food. This shouldn’t come as a surprise: most people that experience food insecurity are likely to be living in low-income communities. The generalization here is that these communities tend to have fewer parks, and if they are present, there tends to be a lot of litter and a cloud of unsafe space hovering over it. 

Arreaza: I see what you mean.

Nausheen: These people will probably be less likely to go out for walks and take their kids out…leading to a sedentary lifestyle. The last association I see is that of mental health. People who are struggling to find food are likely to have stress due to their circumstances and there is a relationship that has been found between depression and the increased likelihood of developing obesity. As a recap, there are three effects of food insecurity that contribute to obesity: lack of adequate nutrition, lack of physical activity, and poor mental health. 

Arreaza: So, there are several factors of food insecurity that seem to be making individuals more likely to develop obesity. Why does it matter? 

Nausheen: Well obesity is the gateway to several other diseases such as diabetes and hypertension, which are known to the medical profession as "silent killer diseases." In short, what we typically refer to as "that person is larger built" can have major adverse effects on health and can substantially reduce a person's longevity and quality of life. If we can understand and reduce risks of developing obesity, we can prevent the onset of the disease and/or prevent the progression to more severe outcomes. To bring this more into perspective, the CDC found that from 2017-2020, 1 in 5 children had obesity and about 2 in 5 adults had obesity, with an overall prevalence of 41.9% in the U.S. 

Arreaza: Let’s talk about possible solutions.

Nausheen: I think the best solution to this issue has to be two parts. 1. Increased access to healthy foods. 2. Nutrition education on how foods you put into your body impact your health both now and long term. I work with urban farmers in Pomona, CA as part of a grassroots effort to increase access to nutritious foods. 

Arreaza: Tell me more about it.

Nausheen: The system consists of several small-scale community farms that produce chemical-free, pesticide-free, fresh vegetables and fruits that are sold to the community members at a low price or a “pay what you can, take what you need” basis. I believe replicating this system in other communities is effective because 1. It is important for the people to know and trust where their food is coming from, and 2. People can volunteer to help the community farms thrive which not only allows for the sustainability of efforts but gives them a reason to be outside and be active which helps combat obesity! 

Arreaza: I believe nutrition education is a key element to combat obesity, but the battle is unfair. I see there needs to be a better effort from our government to control such things as the false advertisement of so-called “healthy foods” and “miracle supplements” that promise the cure of obesity. I feel like there needs to be more control of these vendors and pay for false science. 

Nausheen: Nutrition education itself is also important so that people understand what nutrients their bodies need, what foods can give it to them, how to cook those foods, and lastly how it all affects their health. This should start from elementary school with short lessons embedded into the school curriculum. 

Arreaza: Thank you for sharing that. This brings our episode to a close. If you are or if you know someone who is struggling with food insecurity, find some resources in your community such as food banks, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and other resources. 

Nausheen: Find community gardens where you live.

_______________

Conclusion: Now we conclude episode number 128 “Food insecurity and obesity.” Nausheen explained that a lack of access to fresh and healthy foods is linked to increased risk of obesity. Dr. Arreaza called for improved controls for scammers and pseudoscientists that frequently commit fraud to patients who are struggling with obesity.

This week we thank Hector Arreaza and Nausheen Hussain. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

_____________________

Sources:

1. Hartline-Grafton, H. (2018, April 18). Understanding the connections: Food insecurity and obesity (October 2015). Food Research & Action Center. Retrieved February 5, 2023, from https://frac.org/research/resource-library/understanding-connections-food-insecurity-obesity.
2. U.S. Department of Health and Human Services. (2022, March 24). What are overweight and obesity? National Heart Lung and Blood Institute. Retrieved February 5, 2023, from https://www.nhlbi.nih.gov/health/overweight-and-obesity.
3. Food Security in the U. S. - Measurement. USDA ERS - Measurement. (2022, October 17). Retrieved February 5, 2023, from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/measurement.
4. Craven, K., Patil, S. (unknown). Understanding Food Security & Obesity Paradox: A Case Study. Department of Family Medicine, Brody School of Medicine.
5. Blasco BV, García-Jiménez J, Bodoano I, Gutiérrez-Rojas L. Obesity and Depression: Its Prevalence and Influence as a Prognostic Factor: A Systematic Review. Psychiatry Investig. 2020 Aug;17(8):715-724. doi: 10.30773/pi.2020.0099. Epub 2020 Aug 12. PMID: 32777922; PMCID: PMC7449839.
6. Centers for Disease Control and Prevention. (2022, May 17). Childhood obesity facts. Centers for Disease Control and Prevention. Retrieved February 6, 2023, from https://www.cdc.gov/obesity/data/childhood.html.
7. Centers for Disease Control and Prevention. (2022, May 17). Adult obesity facts. Centers for Disease Control and Prevention. Retrieved February 6, 2023, from https://www.cdc.gov/obesity/data/adult.html
8. Royalty-free music used for this episode: “Gushito - Latin Pandora." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Saakshi presents some updates on the treatment of obesity in pediatric patients. Wendy explains a recent study connecting hair iron to uterine cancer. 

Updates on obesity management in pediatric patients.
Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited by Hector Arreaza, MD.

Background information:

The American Academy of Pediatrics has released new guidelines on obesity management in pediatric patients. This is the first update regarding childhood obesity in 15 years. According to the CDC, the rates of childhood obesity have tripled since the 1980s, and as of now, 1 in every 5 children suffers from obesity in the United States. It is important to recognize obesity is a chronic, multifaceted disease that comes with its own set of complications, such as type 2 diabetes mellitus, high blood pressure, asthma, sleep apnea, heart disease, and various mental and psychosocial health issues. 

The first-line treatment used to be comprised of behavioral health and lifestyle counseling, however, now, 1st line treatment for pediatric patients includes medications and surgery in addition to the previously suggested counseling. This is because research has shown that diet and level of physical activity are not the only factors that determine weight but also include genes, hormones, and metabolism. Similar to many other chronic diseases, the sooner the treatment is started, the better. There has been no benefit shown in waiting for adulthood to treat obesity. 

Who qualifies for which treatments?

As a reminder, in the pediatric population, we use the BMI percentiles instead of the absolute number for BMI. Overweight is defined as BMI between 85-95th for patients of the same gender and age. Obesity is defined as being above the 95th percentile.

Four drugs are now approved for obesity treatment in adolescents starting at age 12, which are Saxenda® (liraglutide), Qsymia® (phentermine-topiramate), Wegovy® (semaglutide), and Xenical® or Alli® (orlistat). Phentermine as monotherapy has been approved for teens aged 16 and older. Another drug called Imcivree® has been approved for children 6 and older affected by Bardet-Biedl syndrome. The problem with medications is that they are not available to everyone due to the cost, and there are many shortages occurring due to the high demand for these drugs. 

Surgical options:

This is a MAJOR change in the recommendations for obesity treatment in children.  The new guidelines recommend discussing SURGERY with patients that are 13 years old and have severe obesity. It has been shown that bariatric surgery provides lasting results but also that it can reverse health issues such as type 2 diabetes mellitus and hypertension. It is exciting that more research is being done to provide us with more evidence regarding the treatment of obesity in children. Obesity treatment is challenging, even more so in children. So, we encourage all listeners to review the new guidelines about the use of medications and surgery to treat obesity in children and put them to practice if appropriate for your patients.

____________________________

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

____________________________

Hair products and uterine cancer.
Written by Wendy Collins, MS3, Ross University School of Medicine. Edited by Hector Arreaza, MD.

What is the sister study? 

The Sister Study is a nationwide effort in the US conducted by the National Institute of Environmental Health Sciences, which includes over 50,000 sisters of women who have had breast cancer. This study aims to find environmental and genetic causes of breast cancer. The women in this study were breast cancer free and lived in the United States, including Puerto Rico. They were enrolled from 2003-2009 and were followed up until September 2019. 

If the sister study is made up of 50,000 women, why does this study only use about 30,000 of those women? 

Excluded women include those who withdrew from the study (n = 3), who self-reported a diagnosis of uterine cancer before enrollment (n = 380), had an uncertain uterine cancer history (n = 10), had an unclear timing of diagnosis relative to enrollment (n = 59), had a hysterectomy before enrollment (n = 15,585), who did not answer any hair product use questions (n = 736), and who did not contribute any follow-up time (n = 164), resulting in 33,947 eligible women. 

How was it done?
The authors reviewed medical records and questionnaires about hair care within the past 12 months and compared women who developed uterine cancer with those who did not for about 10 years between 2003-2009. Of this sample, only 378 women developed uterine cancer. Further investigation needs to be done to make worthwhile associations between hair straighter use and the incidence of uterine cancer. This study drew 2 primary conclusions:

1. Hair products are not associated with uterine cancer: No associations were found between hair product usage and the incidence of uterine cancer. This was investigated because it's thought that synthetic estrogenic compounds, such as endocrine-disrupting chemicals, could contribute to uterine cancer risk because of their ability to alter hormonal actions. This is something that has been linked to breast and ovarian cancers in the past, so it made sense to consider the same for uterine cancers.
2. Using a straightening iron is positively associated with uterine cancer: Ever vs. never use of a straightening iron in the previous 12 months was associated with a hazard ratio of 1.80 with 95% confidence interval 1.12 to 2.88. The association was stronger when comparing frequent use (>4 times in the past 12 months) vs never use was associated with a hazard ratio of 2.55, 95% confidence interval 1.146 to 4.45.

This was investigated because it is thought that heating processes such as flat ironing or blow drying could release or thermally decompose chemicals from the products. This can lead to potential higher exposures to hazardous chemicals through inhalation or percutaneous absorption of chemicals, which is higher in the scalp compared to other areas. 

While this hypothesis makes sense and supports the results, there are many confounding variables, including physical activity. Women with higher physical activity tend to have decreased sex steroid hormones and less chronic inflammation, reducing their risk of uterine cancer.

Hair products are not associated with uterine cancer, and straightening iron is positively associated with uterine cancer, but further research is needed.

The incidence of uterine cancer in the past 20 years has significantly increased. Investigating reasons for why this might be could lead to the discovery of potential targets for intervention. However, I am personally unconvinced by this study, and I fully intend to continue to use hair products, my blow dryer, my curling iron, my crimper, and yes even my straightener for the foreseeable future until further research is done.

__________________________

Conclusion: Now we conclude episode 127 “Obesity Update and Uterine Cancer.” We learned from Saakshi that the American Academy of Pediatrics now recommends discussion of pharmacologic and surgical treatments for pediatric obesity; then Wendy explained that some association between hair iron and uterine cancer was found but further research is needed. 

This week we thank Hector Arreaza, Saakshi Dulani, and Wendy Collins. Audio edition by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

Links:

1. Chang CJ, O'Brien KM, Keil AP, Gaston SA, Jackson CL, Sandler DP, White AJ. Use of Straighteners and Other Hair Products and Incident Uterine Cancer. J Natl Cancer Inst. 2022 Oct 17:djac165. doi: 10.1093/jnci/djac165. Epub ahead of print. PMID: 36245087. https://pubmed.ncbi.nlm.nih.gov/36245087/
2. American Academy of Pediatrics Issues Its First Comprehensive Guideline on Evaluating, Treating Children and Adolescents With Obesity, American Academy of Pediatrics, AAP.org, published on January, 9, 2023, available at: https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-issues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/
3. Gumbrecht, Jamie and Jacqueline Howard, Updated childhood obesity treatment guidelines include medications, surgery for some young people, January 11, 2023. CNN.com, available at: https://www.cnn.com/2023/01/09/health/childhood-obesity-treatment-guidelines-wellness/index.html
4. Sullivan, Kaitlin, New guidelines for treating childhood obesity include medications and surgery for first time, January 9, 2023. NBCnews.com, available at: https://www.nbcnews.com/health/kids-health/new-guidelines-treating-childhood-obesity-include-medications-surgery-rcna64651
5. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

January 20, 2023. Olivia and Janelli explain that caffeine intake during pregnancy may cause short height in babies, and Anthony discusses the definition, evaluation, and management of AKI with Dr. Kooner. 

Introduction: Caffeine consumption during pregnancy. 
Written by Olivia Weller, MS3, American University of the Caribbean School of Medicine; and Janelli Mendoza, MS3, Ross University School of Medicine.

Current Guidelines about caffeine during pregnancy: The American College of Obstetricians and Gynecologists (ACOG) current recommendations are to limit caffeine consumption during pregnancy to 200 mg of caffeine per day. Anything exceeding a moderate level of caffeine intake has been linked to an increased risk for preterm birth and miscarriage. [8 oz of brewed coffee has approximately 137mg of caffeine. Other drinks and foods contain caffeine: Brewed tea 48mg; Decaf coffee (12 oz), 9-15 mg; caffeinated soft drink (12 oz) 37mg, Dark chocolate (1.45 oz) 30mg] 

New Evidence: More recent data disclosed that moderate levels of caffeine consumed during pregnancy led to newborns being small for gestation age (SGA). This information was taken further, and scientists began to monitor these children as they aged. Researchers studied newborns born to mothers who consumed zero caffeine during pregnancy versus women who consumed moderate levels of caffeine. They tracked height, weight, BMI, and obesity risk but only found statistical differences in height. So far, they have only investigated children up to the age of 8 and found that the variance in height increased as the children got older. Therefore, even consuming a moderate level of caffeine during pregnancy can have lasting effects on a child’s height, which likely persists into adulthood. Some professionals are now saying there may be no amount of caffeine that is safe to consume during pregnancy. 

American Family Physician Journal, 2009: “Caffeine intake is directly correlated with small but notable fetal growth restriction. Although a safe threshold cannot be determined, maternal caffeine intake of less than 100 mg per day minimizes the risk of fetal growth restriction.”

Why does smaller birth size matter? Caffeine crosses the placenta and acts as a vasoconstrictor which reduces the blood supply to the fetus and thus hinders proper growth. It is a sympathomimetic agent that can affect fetal stress hormones and increase the risk for rapid weight gain after birth. Although height is not a pressing issue, children are potentially more susceptible to increased risk for certain conditions later in life, such as obesity, heart disease, and diabetes. More research is needed on this front to make the conclusion that these differences do in fact persist into adulthood and lead to adverse health outcomes. 

Conclusions and limitations. Pregnant women and children remain as a group with the least amount of research due to the potential adverse life outcomes. For this reason, the studies that have been done on caffeine consumption during pregnancy are comprised of self-reported data. Due to the association between high caffeine consumption and smoking, it is difficult to distinguish the two. Therefore, there is no clear cause-and-effect relationship between caffeine and intrauterine growth restriction (IUGR), leading to shorter stature later in life. However, the potential adverse health outcomes outweigh the psychological benefits of caffeine during the gestational period. If mothers can give up alcohol, drugs, smoking, raw fish, and so much more during pregnancy, why not caffeine too? With the emergence of this new information, perhaps it is time for a review of those guidelines. 

Welcome: You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

January 20, 2023. Written by Anthony Floresca, MS4, American University of the Caribbean School of Medicine; edited by Hector Arreaza, MD; recording done with Gagan Kooner, MD.

Definition of Acute Kidney Injury (AKI): 

Acute kidney injury is a clinically relevant disease process that often occurs during hospitalizations but can also occur as a result of pre-existing diseases such as diabetes mellitus, hypertension, and congestive heart failure, usually referred to as “AKI on CKD,” i.e., acute kidney injury can present as a worsening of renal function in a patient who already has decreased renal function at baseline. 

AKI is defined as a sudden onset decrease in renal function that can be diagnosed as early as 6 hours from disease onset. To diagnose AKI, specific parameters to consider are creatinine and urine output. Kidney Disease: Improving Global Outcomes or KDIGO established criteria in 2012 for diagnosing AKI:

1. An increase in serum creatinine of ≥ 0.3 mg/dL within 48 hours, [for example, a serum creatinine increasing from 1.3 (baseline) to 1.6]
2. An increase in serum creatinine ≥ 1.5 times baseline within the past week, [for example, an increase in serum creatinine from 1.3 (baseline) to 1.95]
3. A decrease in urine output < 0.5 mL/kg/hr within 6 hours, [for example, a man who weighs 70 kg and is urinating less than 35mL of urine per hour]

Classification:

The severity of AKI is defined under the 2012 KDIGO guidelines: 

Stage I

• Creatinine 1.5-1.9 times greater than baseline or  ≥ 0.3 mg/dL increase in serum creatinine.
• Urine volume < 0.5 mL/kg/hr for ≥ 6-12 hours

Stage II

• Creatinine 1.5-1.9 times greater than baseline or  ≥ 0.3 mg/dL increase in serum creatinine.
• Urine volume < 0.5 mL/kg/hr for ≥ 6-12 hours

Stage III

• Creatinine 3 times higher than baseline OR ≥ 4.0 mg/dL increase in serum creatinine

(Kooner: For example, if a creatinine at baseline is 0.8 and it increases to 2.4, it is stage III)

Anthony: Yes, it is stage III if the patient initiates renal replacement therapy (hemodialysis), OR a decrease in GFR to < 35 mL/min per 1.73 m^2 in patients <18 years old

• Kooner: Urine volume < 0.3 mL/kg/hr for ≥ 24  hours OR anuria ≥ 12 hours

The etiologies of AKI can be divided into three simplified categories: 

Prerenal

Approximately 70% of cases of AKI are due to prerenal causes. This is due to a decrease in intravascular volume which in turn results in decreased renal perfusion. Medications such as ACE inhibitors and NSAID’s are selective vasoconstrictors that essentially decrease the amount of intravascular fluid that enters the kidney. Other causes include decreased perfusion as a result of loss of intravascular fluid such as hemorrhage. 

The pathophysiology of prerenal AKI can be attributed to the renin-angiotensin-aldosterone system (RAAS). RAAS is activated in response to decreased intravascular volume. When intravascular volume is low, renin is secreted by juxtaglomerular cells in the afferent arterioles of the kidney. Renin activates angiotensin I which is converted to angiotensin II in the lungs. Angiotensin II directly activates aldosterone. The most detrimental effect of aldosterone on the kidneys is the vasoconstricting effect it has on the efferent arterioles which in turn decreases renal function.

Intrarenal

Intrarenal causes of AKI are largely due to direct renal damage either due to glomerular or tubular disease. Acute tubular necrosis (ATN) is an example of intrarenal AKI which can be caused by nephrotoxic agents such as certain antibiotics. ATN can also result from prolonged ischemia as a result of prerenal disease. Rhabdomyolysis can result in a large amount of myoglobin released into the blood which ends up being excreted by the kidney and causing intrarenal damage.

Contrast, given prior to imaging studies, is a radioactive compound that is excreted by the kidneys and can cause damage. This is why it is important to know a patient’s renal function prior to ordering studies with contrast. Most often, some proteins and drugs affect tubular cells and reduce their ability to function properly. 

The pathophysiology for intrarenal causes of AKI is variable due to the different mechanisms by which diseases like systemic lupus erythematosus or Goodpasture syndrome lead to nephropathies. 

Postrenal

Postrenal causes are largely structural abnormalities resulting in a subsequent decrease in renal excretion due to obstruction distal to the kidney. Examples are BPH, bladder/ prostate/ cervical cancer, or nephrolithiasis. 

Management:

Most often the physical exam, history, and imaging studies can assist with diagnosing and treating this type of AKI. A patient with a history of fever and weight loss may suggest a diagnosis of cancer. A patient complaining of flank pain and dysuria may have stones that can be managed with lithotripsy. 

Interestingly, a patient with unilateral obstruction may not necessarily develop an AKI as a single kidney can compensate for the affected kidney. The most common cause of postrenal AKI is bladder outlet obstruction due to bladder cancer, bladder stones, or tumors producing a mass effect. This results in bilateral kidney obstruction without adequate compensation. In this scenario, AKI is likely to develop.

Evaluation

Although AKI can manifest acutely, the recovery from AKI can take as long as months to years. Treating AKI is very much dependent on determining the cause. 

For example, if a patient develops AKI following starting a new medication known to be nephrotoxic, it is important to stop the offending agent and consider adjusting the medication to renal dosing or consider alternative treatment options. 

The most important method to determine the cause of AKI is fluid repletion. If a patient improves after receiving fluids, AKI is likely due to a prerenal etiology. AKI resulting from postrenal etiologies will likely improve following resolution or treatment of the distal obstruction. Otherwise, further tests and imaging can be useful in providing further information on the management of a patient with AKI.

Useful labs and imaging for the diagnosis and management of AKI:

• Serum creatinine- definitive for diagnosis based on the criteria above
• Urinalysis- essential in forming an appropriate differential diagnosis. If you find hematuria and proteinuria, you should order a workup for glomerulonephritis.
• The fractional excretion of sodium (FeNa) is the percentage of the sodium filtered by the kidney which is excreted in the urine. FeNa below 1% represents prerenal disease, above 2% represents ATN or other kidney damage.
• CBC- to rule out hemolytic causes of AKI.
• CMP- electrolyte imbalances warrant frequent monitoring and repletion as necessary
• Renal US- to rule out obstructive causes of renal function decline.
• Biopsy- if prerenal and postrenal causes have been excluded; intrarenal causes of AKI may require biopsy and pathology tests to assist with diagnosis.

_____________

Conclusion: Now we conclude our episode number 126 “Caffeine and AKI.” We learned that caffeine intake, even below the recommended 200 mg, may cause an effect on newborns’ height. It may be time to review the guidelines for caffeine intake during pregnancy. Then, we listed to Anthony and Dr. Kooner’s explanation of Acute Kidney Injury. AKI presents when there is a serum creatinine increase of 0.3 mg/dL in 48 hours, or creatinine increase of 1.5 times from baseline, or decreased urine output below 0.5 mL/kg/h. If you keep in mind that definition, you will diagnose your patients in a timely manner to start kidney-saving treatments. 

This week we thank Hector Arreaza, Olivia Weller, Janelli Mendoza, Anthony Floresca, and Gagan Kooner. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

Links:

1. Holcombe, M. (2022) Even less than recommended amounts of caffeine while pregnant could impact your child's life, CNN. Cable News Network. Available at: https://www.cnn.com/2022/10/31/health/caffeine-stature-early-childhood-study-wellness/index.html.
2. LaMotte, S. (2020) Caffeine consumption not safe during pregnancy, new study says. some experts disagree, CNN. Cable News Network. Available at: https://www.cnn.com/2020/08/24/health/caffeine-during-pregnancy-study-wellness/index.html.
3. Moderate daily caffeine intake during pregnancy may lead to smaller birth size (2021) National Institutes of Health. U.S. Department of Health and Human Services. Available at: https://www.nih.gov/news-events/news-releases/moderate-daily-caffeine-intake-during-pregnancy-may-lead-smaller-birth-size.
4. No safe level of caffeine consumption for pregnant women and would-be mothers (no date) BMJ. Available at: https://www.bmj.com/company/newsroom/no-safe-level-of-caffeine-consumption-for-pregnant-women-and-would-be-mothers/.
5. Rhee, J. et al. (2015) “Maternal caffeine consumption during pregnancy and risk of low birth weight: A dose-response meta-analysis of observational studies,” PLOS ONE, 10(7). Available at: https://doi.org/10.1371/journal.pone.0132334.
6. Science update: Caffeine consumption during pregnancy may lead to slightly shorter child height (2022) Eunice Kennedy Shriver National Institute of Child Health and Human Development. U.S. Department of Health and Human Services. Available at: https://www.nichd.nih.gov/newsroom/news/103122-caffeine-consumption-pregnancy.
7. Goyal A, Daneshpajouh Nejad P, Hashmi MF, et al. Acute Kidney Injury. [Updated 2022 Aug 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. https://www.ncbi.nlm.nih.gov/books/NBK441896/.
8. Makris K, Spanou L. Acute Kidney Injury: Definition, Pathophysiology and Clinical Phenotypes. Clin Biochem Rev. 2016 May;37(2):85-98. PMID: 28303073; PMCID: PMC5198510. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198510/.
9. Manzoor H, Bhatt H. Prerenal Kidney Failure. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560678/.
10. Rahman M, Shad F, Smith MC. Acute kidney injury: a guide to diagnosis and management. Am Fam Physician. 2012 Oct 1;86(7):631-9. PMID: 23062091. https://pubmed.ncbi.nlm.nih.gov/23062091/.
11. Royalty-free music used for this episode: “Good Vibes - Sky's the Limit_60 sec." Downloaded on October 13, 2022, from https://www.videvo.net/
12. Royalty-free music used for this episode: “Good Vibes - Sky's the Limit_underscore." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Dr. Axelsson and Jesse explain how to treat chronic pain without opioids. 

Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Axelsson:Welcome to the first episode of 2023, Happy new year! Today is January 10, 2023.

What is chronic pain?

According to the International Association for the Study of Pain, chronic pain is nonstop or reoccurring pain that lasts more than 3 months or beyond the expected clinical course of illness. Chronic pain can adversely affect well-being and quality of life. We used to think of pain as a response to tissue damage, and as the tissue heals, the pain dissipates, but chronic pain is much more complex than that because there may be no evidence of tissue damage, yet the nociceptors keep sending signals to the brain that there is damage.

There are 3 options for the management of chronic pain: non-pharmacologic, nonopioid pharmacological and opioid management. 

CDC recommends a combination of nonpharmacological and non-opioid management for chronic pain. The 7 most common chronic pain conditions are neuropathic pain, fibromyalgia or chronic pain syndrome, osteoarthritis, inflammatory arthritis, low back pain, chronic headache, and sickle cell anemia.

Opioids in long-term care facilities.

The use of opioids for the treatment of pain is common in the post-acute and long-term care setting. From the AFP Journal, the Choosing Wisely Recommendation states: “Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.” 

The Society for Post-Acute and Long-Term Care Medicine published a statement in 2018 about the use of opioids. It states that the prescription of opioids should be based on an interprofessional assessment specifying why opioids are needed. When long-term opioids are not being used for cancer, palliative care, or end-of-life care in a long-term facility, a tapering plan must be “individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications”. 

Long-term opioid prescriptions should be reviewed regularly and take into consideration the potential harms of opioids. Clinicians are encouraged to offer alternatives such as behavioral therapy, non-opioid analgesics, and other non-pharmacologic treatments whenever available and appropriate.

Initial assessment: Identify biopsychosocial factors and identify if the source is neuropathic, nociceptive, or central sensitization. This can be a challenging process and it may require several visits to determine the origin of pain. Neuropathic pain is due to nerve damage or irritation while nociceptive pain is due to tissue damage. Central sensitization is an abnormal response of the nociceptive system. There are changes in the nervous system that alter how it responds to sensory input that causes widespread pain with no apparent cause or in response to mild sensory input. Some examples include fibromyalgia, migraines in response to brushing hair, surgical scar pain, etc.

Set goals and expectations: It is crucial to set up patient expectations if they have chronic pain. They should understand that pain can be improved to a manageable level but not always eliminated. Patients should have routine follow-up visits with education, and reassurance since they are shown to improve outcomes of pain management. Specific goals such as improved mobility and ability to do certain enjoyable tasks are more reasonable and specific goals than a goal of pain elimination. A good physician-patient relationship and clear communication are essential here. Patients could obviously become deeply upset at the prospect of pain that can’t be eliminated, and those who have received opioids for their pain in the past could be even more distraught at the thought of not getting them now or needing to reduce their dose. The physician should be ready to have this discussion with their patients that have chronic pain and be ready to address their concerns appropriately. 

Reduce catastrophic thinking: Pain is an alarm system letting someone know there is some sort of damage. Because of this, it makes sense that a patient would respond to pain with anxious and catastrophic thinking. Patients who understand their own chronic diseases are more likely to be actively involved in their treatment, so understanding is crucial in the management of pain. Reducing fearful thoughts such as "there must be something wrong," and "hurt means harm’” is an important first step toward pain self-management and making sure the strategies attempted are effective.

Rehabilitation: Focused pain clinics often include educational group classes for patients in distress. The programs include explanations for why pain might be present with no pathological factors. It also includes relaxation and mindfulness that help patients soothe themselves during attacks. 

The brain plays a big role in the experience of pain. Changing how your brain relates physical pain to stress and reducing those psychosocial barriers through self-care helps with pain management. Finding things that make you physically stronger like physical therapy or occupational therapy help, but also increasing mental strength by doing things that make you happy and having a quality social life is a strong determinant of how the brain perceives physical pain. Consistency is key in pain management even after the patient begins to feel better.

Non-pharmacologic therapy – Most of what we will talk about today is non-pharmacological treatment. We will discuss the options and goals of different treatments. Chronic pain treatment should start with non-pharmacological approaches and then you can add medications if necessary. Again, these approaches aim to increase functionand reduce progression despite chronic pain. 

There should be a consistent non-pharmacological regimen, even if medications are added later. The three main approaches will be physical therapy, psychological therapy, and some integrative medicine methods.

Physical therapy. The objective of physical therapy is to improve physical function. You should recommend programs that are specific for patients’ limitations and the physical therapist should have trained specifically in chronic pain treatment. This ensures they do a proper initial evaluation and select appropriate therapeutic methods such as 

Therapeutic exercise: Sometimes patients can become so fearful of painful movement that they have deconditioned muscles. In the geriatric population, some patients are so afraid of falling, that they avoid any form of movement whatsoever, therefore almost certainly leading to falls due to deconditioning of those muscles. Adding small amounts of exercise as tolerated can begin to recondition patients and help them build strength. Patients with severe osteoarthritis are more likely to tolerate aquatic exercises. 

Therapeutic exercise programs may be available at the physical therapy facility or community centers. Patients can even find videos on the internet of tai chi, yoga classes, Pilates, and low-impact fitness programs. Exercise can certainly reduce pain and improve function, with few adverse effects but make sure patients tolerate the exercises and are not pushed beyond their limits. Stretching can also improve range of motion and strength, especially in chronic lower back pain patients. 

Psychological therapy:

Cognitive-behavioral therapy. It is the most researched and recommended psychological treatment for chronic pain. It’s normally recommended in conjunction with patient education, physical therapy, and exercise. CBT can be used after introducing meds and/or after surgery. There are 2 components to cognitive behavioral therapy: cognitions and behaviors. CBT addresses the way that patients’ thoughts (cognitions) affect their actions and vice versa. This begins with helping patients identify situations and environments that trigger their pain and what they actually experience emotionally, behaviorally, and physically when they have pain.

CBT addresses mental responses that may worsen pain, so patients learn to think about how they view their pain. To do this, they use a range of specific behavioral strategies such as relaxation and controlled-breathing exercises, activity pacing, pleasurable activities, improving their sleep, and cognitive reappraisal strategies, such as reframing negative situations to positive or practicing gratefulness.

Complementary and integrative health therapies.

-Mindfulness-based stress reduction. Mindfulness is the ability to be fully present where we are and what we’re doing, and not be overly reactive or overwhelmed by what’s going on around us.

-Progressive muscle relaxation. For instance, tensing/relaxing muscles throughout the body along with positive imagery and meditation.

-Biofeedback. During biofeedback, you’re looking at biological signs, and feedback that is being correlated to physical sensations in your body to recognize the correlation between physical signs and symptoms of chronic pain. You’re connected to monitors, such as electromyograms or electroencephalograms, to quantify muscle tension, brain waves, heart rate, and blood pressure to see how fluctuations and abnormal numbers physically feel in the body.

-Massage therapy. 

It can relax painful muscles, tendons, and joints and relieve stress. The effect of pressure in certain areas that are tender causes relaxation and secretion of endorphins that can calm pains. That’s why massage therapy can actually be addictive for some people, because of the endorphins. Another benefit of massage therapy is that it can help with improved absorption of medications due to improved circulation.

There are many other integrative health therapies including Reiki, hypnosis, therapeutic touch, healing touch, and homeopathy. However, these are not well-researched and can’t really be endorsed by evidence-based medicine.If patients are interested in trying complementary, integrative health therapy, you can guide them to practices that are at least safe. 

Some therapies can end up being harmful, such as herbal remedies or supplements with potential toxicities or known interactions with medications, so those should be taken cautiously. Make sure your med list while taking your history includes supplements and herbs patients might be trying. 

Shirodhara is an Ayurvedic approach to stress relief that involves having someone pour liquid — usually oil, milk, buttermilk, or water — onto your forehead.

Herbal or plant-based treatments have also shown some efficacy in published studies. Ginger, turmeric, St John’s Wort, and a handful of others seem like they could have some beneficial effects either on their own merit or as an adjunctive with other non-opioid therapies. Caution should be taken, though, as some of them, particularly St John’s Wort, have been shown to have negative impacts on serum levels of opioids when used in combination with them due to their effects on the liver cytochrome system. Data is also rather mixed, with some studies showing reasonable efficacy and others showing almost none. If your patients want to take herbal supplements, it is essential to be diligent about checking their efficacy and interactions with other therapies to ensure safety. The physician should also be clear when discussing current medications to ask specifically if they take herbal supplements of any kind, as many patients don’t consider these to be “medications” and will omit them during history. Of note, turmeric has to be taken with black pepper for better GI absorption.

Weight reduction: A healthy diet and fitness are always recommended. Online guidelines are helpful on topics such as healthy fats, vegetables, avoiding refined sugar, and more. Obesity is a pro-inflammatory state, but it is important not to blame chronic pain problems solely on obesity since patients may still have pain after losing weight. Weight reduction can be a part of that plan, but we should not promise a cure for chronic pain after a patient reaches an ideal weight. 

Sleep disturbances: Ironically, sleep improves pain, but pain makes sleep more difficult. If patients complain of sleep disturbances, start with behavioral changes, including improved sleep hygiene (keep a regular sleep schedule, exercise regularly, don’t use caffeine and caffeinated beverages, don’t eat too late at night) and stimulus control (the bed should only be used for two things: sleep and sex, get out of bed if you can’t sleep, wake up at the same time every day, and avoid bright screens before bedtime because they confuse your brain); cognitive behavioral therapy (deal with concerns or worries that may interfere with sleep). Treating sleep disturbance may have a positive effect on the treatment of chronic pain. 

Acupuncture: It involves the insertion of very thin needles through the skin at specific points on the body. Acupuncture is a key component of traditional Chinese medicine and can be considered in patients with chronic pain. There are significant difficulties in studying acupuncture, but randomized trials suggest that acupuncture and placebo may have similar efficacy, and both are superior to no treatment. 

Pharmacologic therapy – For patients with inadequate analgesia despite nonpharmacologic therapies, we add carefully selected multi-targeted pharmacological therapies based on the type of pain (i.e., nociceptive, neuropathic, central sensitization) 

For nociceptive pain, start with non-steroidal anti-inflammatory drugs (NSAIDs) while continuing non-pharmacologic treatments. If that doesn’t work add a topical agent such as lidocaine, capsaicin, or topical NSAIDs. Consider opioid treatment if neither of those works. 

For neuropathic pain, start with antidepressants or antiepileptic drugs: tricyclic antidepressants, SNRIs, pregabalin, gabapentin, or carbamazepine in addition to non-pharmacologic therapy. If those medications do not provide relief of pain, then you can consider adding topical agents and then opioids after weighing the risk and benefits. Side effects can be viewed as harmful, but we can use them for our benefit.

Opioids are reserved for people with moderate to severe pain who cannot function. Once you identify a treatment that works for the patient, follow-up visits should be continued to promote behavioral changes, monitor therapeutic response, and treat side effects. A pain contract should also be signed.

Follow-up visits – Schedule follow-up visits to continue educating patients and their families and caregivers, to continue motivational interviewing, and to monitor improvement. Refer patients who are not making enough progress, such as not reaching goals of function and quality of life, to comprehensive pain programs that can use additional modalities such as injections.

Bottom line: Non-pharmacologic options should be considered in the management of all patients with chronic pain. The main non-pharmacologic strategies include physical therapy, psychological therapy, and complementary and integrative therapy. Remember to treat sleep disturbances and obesity as part of your plan. Add pharmacologic agents such as NSAIDs, antidepressants, and anticonvulsants when non-pharmacologic therapies do not help the patient reach their goals. Consider opioids only in moderate to severe pain with loss of function. Opioid prescription is a complex topic that was addressed in episode 31 of this podcast, more than 2 years ago, it is time for an update. Stay tuned, we will talk about opioids soon.

____________________________

Conclusion: Now we conclude episode number 125, “Non-opioid Chronic Pain Management.” Non-pharmacologic therapy is proven to be effective in the treatment of chronic pain, especially physical therapy, psychological therapy, and some complementary therapy. Medications can be added to non-pharmacologic therapy, mainly NSAIDs, antidepressants, antiepileptic medications, and more. Opioids can be added in disabling chronic pain, but prescription needs to be done cautiously and watchfully. The treatment of chronic pain may be challenging and daunting at times, but fortunately, we have science to back us up with effective ways to help our patients. So, don’t be discouraged and trust science! 

This week we thank Fiona Axelsson, Jesse Lamb, and Hector Arreaza. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

Links:

1. Tauben, David, Brett R Stacey, Approach to the management of chronic non-cancer pain in adults, UpToDate. Last updated on May 06, 2022. Accessed January 10, 2023. https://www.uptodate.com/contents/approach-to-the-management-of-chronic-non-cancer-pain-in-adults.
2. Choosing Wisely Recommendations: Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life, American Family Physician, Collections 460, American Academy of Family Physician. Link: https://www.aafp.org/pubs/afp/collections/choosing-wisely/460.html.
3. What is Mindfulness? Mindful.org. https://www.mindful.org/what-is-mindfulness/.
4. Jahromi B, Pirvulescu I, Candido KD, Knezevic NN. Herbal Medicine for Pain Management: Efficacy and Drug Interactions. Pharmaceutics. 2021; 13(2):251. https://doi.org/10.3390/pharmaceutics13020251.
5. Royalty-free music used for this episode: “Good Vibes - Fashionista." Downloaded on October 13, 2022, from https://www.videvo.net/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Drs. Axelsson, Kooner, and Arreaza explain the basics of medical Spanish.

Hi! Thank you for joining us for this episode of Rio Bravo qWeek. This is a bonus episode on medical Spanish for beginners. We will teach you the most basic Spanish words you can use during interactions with Spanish-only speakers. Grab your notepad and follow along phonetically! We will also post a transcript of this episode so that you can see the words if you’re a visual learner.

Introductions of participants:

Fiona: Hi, my name is Fiona and I am a 3rd-year resident here at Rio Bravo Family Medicine. I’m also Canadian, so my Spanish was not good when I came to this program. I’m hoping this episode will help me brush up on my Spanish and that it will also help you! Whether you’re a medical student or resident, we could all use a refresher on basic medical Spanish. With me today I have Dr. Hector Arreaza and Dr. Gagan Kooner.

Arreaza: Hi, I’m Hector Arreaza, and I’m a frequent host for this podcast. You may be used to my soft and somewhat unintelligible voice [humor]. I’m from Venezuela, I know some Spanish. 

Kooner: Hi, I’m Dr. Gagan Kooner. I am a PGY1 at Rio Bravo family medicine. I am Punjabi. grew up in Bakersfield. So, when I heard about this episode of the qWeek podcast, I knew I wanted to be a part of it.

Fiona: He’s been modest, his wife is Hispanic.

Preliminary information:

Arreaza: Not everyone who looks “Hispanic” speaks Spanish. We have people in our community from different indigenous groups, mostly from Mexico, and Central America who speak Spanish as a second language. Hispanics have different levels of English proficiency.

Fiona: Hispanic is not a race–it is a culture. Hispanics can be of different races, ranging from White Europeans, Black, Indigenous, and even of Asian descent.

Kooner: Not all Hispanics are Mexicans: Mexico is the country with the highest number of Spanish speakers, but there are 20 Spanish-speaking countries in the world. Spanish has many variations in some countries.

Basic pronunciation:

Fiona: Thank you Dr. Arreaza and Dr. Kooner. Just to set the agenda, as all good clinicians do, let’s lay out what we will discuss. First, we’ll start with Greetings and Common Courtesies. Once we’ve mastered that, we will move on to body parts and family members. Is anyone feeling like they’re back in kindergarten? Next, we will focus on Critical Questions and a brief ROS. This will be helpful in your emergency medicine and hospital medicine rotations. We will then learn how to master a physical exam in Spanish and will end with Good-bye’s and a few miscellaneous items like “Más o Menos”. 

Dr. Arreaza, why don’t you give us a quick intro into Spanish vowels!

Dr. Arreaza: Thank you Fiona, I think that’s a great idea. In Spanish, all of our vowels are pronounced exactly like they sound. A-E-I-O-U

Introduce yourself:

Fiona: Alright, so let’s say I knock on my patient’s door and want to introduce myself by saying, “Good morning, my name is Dr. Axelsson.” 

Kooner: And as a side note: we will repeat the phrases a couple of times so that we can all master the language.

Arreaza:

—[good morning] Buenos días

—[buenas tardes] Good afternoon

—[buenas noches] Good evening 

—“Hola, Me llamo Fiona, estoy esperando al intérprete” [Hi, my name is Dr. Axelsson, I‘m waiting for the interpreter]

—Kooner: Note that doctor is for male and doctora is for female.

—Estoy aprendiendo español [I’m learning Spanish]. 

—Por favor, hable despacio [please speak slowly]
—¿Cómo se llama? [what is your name?]

Common courtesy words:

Fiona: Okay, now that we can say hello and let them know who we are and what we’re doing, can we go over a few pleasantries?

Gracias [thanks]

Por favor [please]

Mucho gusto [nice to meet you]

Igualmente [same to you]

Muy bien [okay]

Bueno [good]

Lo siento [excuse me, sorry] - Disculpe

Espere un momento [one moment]

Body parts: 

Fiona: Alright, now let’s throw it back to grade school and go over body parts from head to toe, or in medical lingo, craniocaudal!

cabeza [head]

ojos [eyes]

nariz [nose]

boca [mouth]

oídos [ears]

pecho [chest]

corazón [heart] Spain

pulmones [lungs]

hombros [shoulders]

brazos [arms]

manos [hands]

dedos de las manos [fingers]

espalda [back]

estómago [abdomen]

pene [penis]

vagina [vagina]

ano or cola [anus]

caderas [hips]

piernas [legs]

rodillas [knees]-Argentina

dedos de los pies [toes].

People:

Kooner: Amazing! We are doing really well with this. I think I’ll be fluent by Friday. 

Fiona: Speak for yourself, Dr., Kooner.

Kooner: Since we’re on a winning streak, let’s keep going and describe relationships in our lives.

Familia [family]

Yo soy [I am]

mamá [mom]

papá [dad]

hermano [brother]

hermana [sister]

hijo [son] – Mijo - niño

hija [daughter] – Mija - niña

niño [boy]

niña [girl]

esposo [husband]

esposa [wife]

abuelo [grandfather]

abuela [grandmother]

tío [uncle]

tía [aunt]. 

Kooner: ROS: 

Fiona: So let’s run through a Review Of Systems, so that in an emergency, I can try to get as much information from my patient as I can, while waiting for the interpreter.

Dr. Arreaza: Have you read The Onion article about a medical student who obtains an entire history with just one Spanish word?

Fiona and Kooner: No, please tell us!

Dr. Arreaza: Dolor! [pain]
dolor de cabeza [headache]

sangrado [bleeding]

fiebre or calentura [fever]

escalofríos [chills] 

ardor al orinar [burning with urination]

dolor de estómago [abdominal pain] – Kooner: Dolor de panza

hinchazón [swelling]

comezón [itching]

palpitaciones [palpitations]

mareos [dizziness or lightheadedness]

tos [cough]

sangre [blood]

Physical exam: 

Kooner: Okay, so let’s say I want to examine a patient. How do I ask them to “please sit here.” Por favor, siéntese aquí.

respire profundo [take a deep breath]

respire normal [breath normally]

abra la boca [open your mouth]

saque la lengua [stick out your tongue]

¿puedo tocarle el estómago? [can I touch your abdomen]

¿duele? [does it hurt?]

Kooner: Miscellaneous: 

pastillas [pills]

medicamentos [medications]

más o menos [more or less, so-so]

mejor [better]

peor [worse]

más [more]

menos [less]

un poquito [a little bit]. 

hasta luego [see you later]

adiós [bye]

¿tiene preguntas? [do you have any questions?] 

salida [exit]

salud-dinero-amor [when you sneeze, health-money-love]

Position:

Fiona: Okay, so I think there’s an elephant in the room. And if there are any radiologists or surgeons listening, you probably think we forgot about these crucial words! Can you think of what it is? 

Arreaza: Derecha, izquierda.

Yes! We saved the best for last. Left and right! So how do I say right?
Dr. Arreaza: Derecha.
Fiona: Okay and how do I say left?
Dr. Arreaza: Izquierda
Fiona: Oh geez, that’s a mouth full. Izzquierrrrda.

Other words: 

aquí [here]

arriba [up]

abajo [down]

delante [front]

detrás [back]

Dr. Kooner: Well, that is a wrap on our Basic Medical Spanish Podcast, I hope you all enjoyed it.

Fiona: Well, I don’t know about our listeners, but I know I will listen to it on repeat until I am speaking Spanish in my sleep. Thank you for having me, Dr. Arreaza.

_____________

Adrianne: Now you are ready to start practicing these few words. We hope this episode was helpful and enjoyable for you. This week we thank Fiona Axelsson, Gagan Kooner, and Hector Arreaza. Audio editing by Adrianne Silva… and during this special season, we wish you a FELIZ NAVIDAD!

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

______________

1. Royalty-free music used for this episode: The Wassail Song by Videvo, downloaded on December 17, 2022, from https://www.videvo.net/royalty-free-music-track/the-wassail-song/232491/.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Kaitlen defines spontaneous bacterial peritonitis (SBP) and also explains the diagnosis and management.  

Written by Kaitlen Roy-Ross, MS4, Ross University School of Medicine. Moderated by Hector Arreaza, MD. 

Definition:

An ascitic fluid infection with no obvious surgically treatable intra-abdominal source (bowel perforation, abscess, perforated ulcer). Commonly seen in patients with cirrhosis and ascites. 

Patients may have symptoms of fever, abdominal pain, abdominal tenderness, altered mental status, and hypotension.

Etiology: The most common pathogens (75%) are gram-negative aerobic organisms. Klebsiellapneumoniae accounts for 50% of the cases. Gram-positive aerobic bacteria (Streptococcus pneumoniae or viridans group streptococcus) account for the remaining cases. 

Some report E. coli as the most common cause of SBP. Random information: in Korea, Aeromonas hydrophila is an important pathogen of SBP during the summer. 

Diagnosis: To diagnose SBP, a paracentesis should be performed to analyze the ascitic fluid prior to treating the patient with antibiotics.

The ascitic fluid should be analyzed for the following: 

• PMN (Polymorphonuclear cell) count: > or = to 250 cells/mm3 
• Aerobic and anaerobic cultures
• Serum ascites albumin gradient (serum albumin-ascitic albumin): this measures portal pressure.

If the gradient is > 1.1 = portal HTN is present (cirrhosis, heart failure, large liver malignancy, alcoholic hepatitis, portal vein thrombosis) – SBP is likely.

If the gradient is <1.1= portal HTN NOT present (peritoneal carcinomatosis or tuberculosis, pancreatitis, nephrotic syndrome) – SBP less likely.

• Ascites fluid total protein concentration: (<1 g/dL): When protein concentration in ascitic fluid is less than 1 g/dL, there is a low concentration of ópsonins (proteins that bound to bacteria to induce phagocytosis) and patients are at high risk for SBP. The concentration of protein in the peritoneal fluid does not change during SBP. So, if the protein concentration is high, think about secondary bacterial peritonitis. 
• Glucose: > 50 mg/dL
• LDH: 43 +/- 20
• Amylase- will be increased in pancreatitis or gut perforation. No SBP.
• Bilirubin- increased bilirubin in ascitic fluid greater than serum bilirubin or > 6 mg/ suggests a gallbladder perforation. No SBP.

Treatment:

The treatment for spontaneous bacterial peritonitis is broad-spectrum antibiotics. 

Empiric treatment is indicated if a patient with ascites has any of the following:

• Temperature > 100 F
• Abdominal pain or tenderness
• Altered mental status
• PMN in ascitic fluid > 250 (but if there is bacteria in ascitic fluid, start antibiotics stat)
• Alcohol-induced hepatitis

*Important note: Patients on beta blockers should have them permanently discontinued prior to treatment for SBP as beta blockers are associated with worse outcomes. In one study, patients on beta blockers had a 58% increase in mortality risk compared to patients not treated with beta-blockers. Beta-blockers were also associated with higher rates of hepatorenal syndrome and longer lengths of hospital stay.

1st line treatment- 3rd generation Cephalosporin Cefotaxime 2g IV Q8H (preferred) or Ceftriaxone 2 g per day

2nd line treatment- Carbapenems. Usually reserved for patients with severe disease/critical illness.

3rd line- Fluoroquinolones- Cipro 400 mg IV BID to patients with normal renal function. (Patients should not get this if they already receiving it prophylactically.)

Duration of treatment:

5 days, then re-assess the patient’s PMN count:

PMN <250:  Stop ABX treatment

PMN >250 or greater than pre-treatment PMN count > look for a surgical source of infection.

If PMN is > 250 but less than pre-treatment value, continue ABX for 48 more hours and then repeat paracentesis. 

Note: In general, ascitic fluid PMN count should be reduced by at least 25% after 48 hours of antibiotic therapy.

Renal failure is the major cause of death in patients with SBP and develops in 30-40 % of the patients. We can decrease this risk by administering IV albumin. IV albumin should be given when the creatinine is > 1 mg/dl, the blood urea nitrogen is > 30 mg/dl, or the total bilirubin is > 4 mg/dl. Treatment with octreotide or midodrine is helpful if renal failure develops.

Prevention:

Antibiotic prophylaxis can be given to patients with risk factors for SBP. Some risk factors include prior history of SBP, variceal hemorrhage, or an ascites fluid protein concentration of <1 g/dL.

Early preventative measures in patients with risk factors are:

• Early diagnosis and treatment of infections to prevent bacteremia (any infections). (Add comments)
• Diuretic therapy. (Add comments)
• Restriction of PPI’s. (Add comments)

Prophylaxis with antibiotics is indicated for:

1. Patients with cirrhosis who are hospitalized for reasons other than SBP or GI bleeding:

• Oral TMP-SMX (1 DS tablet daily) with discontinuation of the drug at discharge.

1. Patients with a history of 1 or more SBP episodes and patients with low protein ascites along with either renal or liver failure:

• Prolonged outpatient TMP-SMX (1 tablet DS daily). Alternative: Ciprofloxacin 500 mg per day.

1. Patients with advanced cirrhosis and GI bleeding 

• Ceftriaxone 1 g IV and switch to oral TMP-SMX (1 DS tablet 2x daily) once bleeding has stopped and the patient is stable.

____________________________

Conclusion: Now we conclude our episode number 123 “Spontaneous Bacterial Peritonitis.” Let’s not hesitate in the diagnosis of SBP in patients with cirrhosis who present with typical symptoms. The analysis of peritoneal fluid is key in the diagnosis and management of SBP, remember that a peritoneal fluid with PMN above 250 and low protein is highly suggestive of SBP, so, start empiric antibiotics promptly.

This week we thank Hector Arreaza, Kaitlen Roy-Ross, and Gaga Kooner. Audio edition by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

Links:

1. Runyon, Bruce A. Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis, Up to Date, last updated: March 21, 2022. https://www.uptodate.com/contents/spontaneous-bacterial-peritonitis-in-adults-treatment-and-prophylaxis. Accessed December 13,  2022.

1. Ameer MA, Foris LA, Mandiga P, et al. Spontaneous Bacterial Peritonitis. [Updated 2022 Jul 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448208/

1. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 122: Chronic Kidney Disease Overview

Future Dr. Westwood discusses with Dr. Arreaza the evaluation and treatment of CKD before renal replacement therapy. This is a broad overview of CKD.

Written by Daniel Westwood, MSIV, Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.

Definition of CKD:

CKD is defined as abnormal kidney structure or function lasting more than three months with associated health implications. Indicators include albuminuria, urine sediment abnormalities, abnormal renal imaging findings, serum electrolyte or acid-base derangements, and decreased glomerular filtration rate (GFR).

Stages of CKD are based on GFR - CKD1 normal or high >90, CKD2 60-89, CKD3 <60 (3a 45-60), 3b (30-45), CKD4 <30, CKD 5 <15.

CKD can progress to advanced renal failure, end-stage renal disease, and even death; early detection is critical for initiating timely therapeutic interventions, limiting nephrotoxin exposure, preventing further reduction in GFR, and preparing for renal replacement therapy. 

Screening guidelines:

• Annual screening for CKD in pts with DM or HTN (AAFP and National Kidney Foundation)
• Other risk factors that may indicate screening: cardiovascular disease, older age, hx of low birth weight, and family hx of CKD.
• USPSTF recommends against screening asymptomatic adults
• American College of Physicians recommends against screening asymptomatic adults without risk factors.

How to screen? Multiple guidelines recommend at least annual screening with serum creatinine, urine albumin/creatinine ratio, and urinalysis (especially in diabetes mellitus, hypertension, and a history of cardiovascular disease).

1. Full medical history, including:
   • Exposure to potential nephrotoxins (NSAIDS, aminoglycosides, amphotericin B, IV contrasts.)
   • Review past and present blood pressure.
   • Dietary history: Western diet, high in calories, high in animal proteins, and low in fruit and vegetable content.
   • Recent weight gain is essential for CKD evaluation because weight gain may be a sign of fluid retention.
   • Obesity can be a risk for CKD.
2. Review of systems: Generalized weakness, decreased exercise tolerance, impaired cognitive function, decreased urination, foamy urine (proteinuria), anorexia, altered taste (dysgeusia), vomiting, skin changes, lower extremity edema, periorbital edema, shortness of breath, hallucinations (advanced stages).
3. Physical examination:
   • Clinical findings vary with the severity and chronicity of symptoms. It would be difficult to explain all the physical findings in a short time, but it is important to mention that some signs and symptoms may take years of chronic disease to develop, and sometimes patients may have CKD and not know it.
   • General exam: Chronically ill, tired, chronically ill, slow responses due to the accumulation of multiple toxins, including urea. Vitals: BP is elevated, or the patient is currently taking antihypertensives. The skin can be extremely dry, scaly, itchy, pale, or darker than usual for the patient, or you may see a rash.
   • Edema: pitting, bilateral, generalized, especially around the eyes.
   • Auscultation: Signs of fluid overload (bibasilar crackles, cardiac gallops, murmurs)
     • Signs of severe uremia: Uremic fetor (urine smelling), encephalopathy, uremic frost (urea crystals over the skin).
4. Laboratory:
   • Spot urine for albumin-to-creatinine ratio (ACR) to detect albuminuria
   • Serum creatinine to estimate glomerular filtration rate (GFR), serum electrolytes, fasting lipids, hemoglobin A1C
   • Urinalysis: High sensitivity for heavy proteinuria (> 300 mg in 24 hours, estimated from the spot urine protein/creatinine ratio) but may not detect clinically significant lower levels (30 to 300 mg).
   • 24-hour urine collections are no longer recommended as an initial diagnostic tool because of the potential for inadequate collection, inconvenience to patients, and the lack of diagnostic advantage over the urine albumin/creatinine ratio.
   • Imaging: Renal ultrasound to evaluate for structural abnormalities.

Markers of Kidney Damage:

• Proteinuria: Identifies increased risk of cardiovascular disease and mortality
• Albuminuria:
  • microalbuminuria and macroalbuminuria have been replaced with
    • normal to mildly increased (albumin/creatinine ratio less than 30 mg/g)
    • moderately increased (30 to 300 mg/g)
    • severely increased (greater than 300 mg/g)
    • severe albuminuria independently predicts mortality and end-stage renal disease.

Common etiologies of CKD

• hypertensive kidney disease
• diabetic nephropathy
• primary or secondary glomerulonephritis

Management of CKD

Treat reversible causes of CKD

• Avoid nephrotoxic drugs (NSAIDs)
• Identify and treat urinary tract obstructions

Slow the rate of progression by treating underlying causes:

• Control BP
• Diabetes mellitus
• Obesity
• Autosomal dominant polycystic kidney disease (ADPKD)
• Glomerular disease (steroids)
• Viral infections: Hep B, C, HIV
• Hematologic disorders: Renal amyloidosis
• Cardiac or Hepatic disorders: Cardiorenal and hepatorenal syndromes

For patients with proteinuria: Control blood pressure with ACE inhibitors or ARBs and SGLT-2 inhibitors.

Other renal protection methods: Protein Restriction (≤0.8 g/kg/day, increase plant source), Sodium (<5 g/day of table salt), smoking cessation, treating chronic metabolic acidosis w/bicarbonate (slows progression to ESRD), strict glycemic control.

Medications in CKD: For patients with type 2 diabetes who have estimated albuminuria ≥30 mg/day despite an ACE inhibitor (or ARB) and an SGLT2 inhibitor, it is recommended to treat with a nonsteroidal selective mineralocorticoid receptor antagonist (MRA, specifically finerenone), but avoid in those who have serum potassium >4.8 or eGFR<25. 

When to Refer to Nephrology:

Per National Kidney Foundation - Nephrology consultation is indicated for patients with:

• estimated GFR less than 30 mL/minute/1.73 m2
• persistent urine albumin/creatinine ratio greater than 300 mg/g
• urine protein/creatinine ratio greater than 500 mg/g
• if there is evidence of a rapid loss of kidney function
• See Figure 21

Per AAFP – consult a nephrologist when there is AKI on CKD, family history of renal disease, RBC casts in the urine, progression of CKD, resistant anemia, refractory hypertension, serum potassium persistently high, mineral and bone disorders, nephrolithiasis, preparation for hemodialysis.

Bottom line: CKD is a major concern for patients with DM and HTN, but it can have multiple causes. Make sure you screen your patients for CKD and start treatment early to prevent end-stage renal disease. 

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Conclusion: Now we conclude episode number 122, “Chronic Kidney Disease Overview.” Future Dr. Westwood and Dr. Arreaza discussed common signs and symptoms of CKD, and how we can evaluate patients with CKD. Remember to screen your patients with diabetes and hypertension for CKD at least once a year. You may opt to order either a serum creatinine, a urine albumin/creatinine ratio, or just a urinalysis. Once CKD has been diagnosed, your main goal is to prevent end-stage renal disease. Keep in mind at least 3 medications from this episode: ACE inhibitors, SGLT-2 inhibitors, and MRAs. 

This week we thank Hector Arreaza and Daniel Westwood. Audio edition by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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1. Gaitonde, D. Y., Cook, D. L., & Rivera, I. M. (2017, December 15). Chronic kidney disease: Detection and evaluation. American Family Physician. Retrieved October 18, 2022, from https://www.aafp.org/pubs/afp/issues/2017/1215/p776.html
2. Quick reference guide on Kidney Disease Screening. National Kidney Foundation. (2018, March 1). Retrieved October 15, 2022, from https://www.kidney.org/kidneydisease/siemens_hcp_quickreference
3. Rosenberg, M., Curhan, G. C., & Forman, J. P. (2022, April 21). Overview of the management of chronic kidney disease in adults. UpToDate. Retrieved October 13, 2022, from https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-adults
4. Kramer H. Diet and Chronic Kidney Disease. Adv Nutr. 2019 Nov 1;10(Suppl_4):S367-S379. doi: 10.1093/advances/nmz011. PMID: 31728497; PMCID: PMC6855949. https://pubmed.ncbi.nlm.nih.gov/31728497/.
5. Royalty-free music used for this episode: “Keeping Watch,” New Age Landscapes. Downloaded on October 13, 2022, from https://www.videvo.net/royalty-free-music-albums/new-age-landscapes/.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!